Facts on Vascular Dementia and How it Impacts the Cognitive Structure

Vascular dementia is second only to Alzheimer’s as the most prevalent cause of dementia. It accounts for approximately 20-40 percent of dementia cases and it’s estimated that 60 percent of dementia patients have some overlap with Vascular Dementia. With the support of our friends at the Alzheimer’s Association, we’ve created the following guide to identifying the symptomatology of Vascular Dementia and developing a care strategy once the condition is uncovered.

What is the cause?

Vascular Dementia is a cognitive impairment caused by blocked or reduced blood flow to the brain. As the brain has one of the body’s richest networks of blood vessels, it’s particularly sensitive to restricted blood flow and the subsequent lack of oxygen and nutrients.

Vascular Dementia can happen in conjunction with other conditions such as Alzheimer’s disease and Lewy Body Dementia. Research has shown that vascular changes and other brain abnormalities may interact in ways that increase the likelihood of a dementia diagnosis.

While a major vascular blockage from a stroke is the obvious culprit for vascular dementia, a common cause can also be mini-strokes that block smaller blood vessels leading to a cumulative impact on the patient. Cognitive issues in these cases may also begin small and increase over time. A growing number of experts are using the term “Vascular Cognitive Impairment (VCI)” instead of Vascular Dementia, as highlights the thinking changes that can range from mild to severe.

Similar to Alzheimer’s, age is a risk factor for Vascular Dementia. Other risk actuators are the same as for other vascular conditions that impact blood vessels such as heart conditions or stroke. Likewise, mitigation strategies for these conditions can have a positive impact on a patient’s risk for Vascular Dementia.

Symptoms of Vascular Dementia

Signs of Vascular Dementia can be tough to spot. Traditional Alzheimer’s signs, such as memory loss, may or may not be present based on the areas of the brain experiencing reduced blood flow. Since this condition can result from an accumulation of damage, other symptoms can also start gradually. Early indications that are common include impaired planning and judgment, uncontrolled laughing and crying, a reduced attention span, improper functioning in social situations and difficulty finding the right words when speaking.

Symptoms that occur as a result of a major stroke may be more pronounced. After the stroke event, alterations in cognitive abilities could include confusion, disorientation, trouble speaking or understanding speech and vision loss.

Screening and Diagnosis

We recommend screening for Vascular Dementia for high-risk categories of patients, including patients that have had a stroke or a transient ischemic attack (TIA or ministroke). Other patients at high-risk for stroke can also be considered for Vascular Dementia screening including patients with high blood pressure, high cholesterol, or risk factors for heart or blood vessel disease. Depression commonly coexists with brain vascular disease and can contribute to cognitive symptoms so it should also be considered when evaluating risk.

The following are considered core elements of a workup for vascular dementia:

• A thorough medical history, including family history of dementia
• Evaluation of independent function and daily activities
• Input from a family member or trusted friend
• In-office neurological examination assessing function of nerves and reflexes, movement, coordination, balance and senses
• Laboratory tests including blood tests and brain imaging

An effective cognitive screening is typically included during an Annual Wellness Visit (AWV) and recommending an AWV can throw a wider net to screen patients that may be showing subtle signs of vascular dementia, even if they are not considered in a high-risk category.

The following scientific statement was issued by the American Heart Association (AHA) and the American Stroke Association (ASA) in 2011. It has been endorsed by the Alzheimer’s Association and the American Academy of Neurology (AAN). The statement indicates that the following three criteria suggest the greatest likelihood that mild cognitive impairment (MCI) or dementia is caused by vascular changes:

• “The diagnosis of dementia or mild cognitive impairment is confirmed by neurocognitive testing, which involves several hours of written or computerized tests that provide detailed evaluation of specific thinking skills such as judgment, planning, problem-solving, reasoning and memory.
  
• There is brain imaging evidence, usually with magnetic resonance imaging (MRI), showing evidence of either:
  • A recent stroke, or
  • Other brain blood vessel changes whose severity and pattern of affected tissue are consistent with the types of impairment documented in neurocognitive testing.

• There is no evidence that factors other than vascular changes are contributing to cognitive decline.”

The guidelines also discuss cases where the diagnosis may be less clear-cut, such as the common situations where vascular changes coexist with brain changes associated with other types of dementia.

Treatment strategies

The U.S. Food and Drug Administration (FDA) has not approved any drugs specifically to treat symptoms of vascular dementia. There is some indication that certain drugs used to treat Alzheimer’s, including cholinesterase inhibitors such as Donepezil, Rivastigmine and Galantamine, as well as Memantine, may be effective in mitigating some Vascular Dementia symptoms.

There is no treatment to reverse damage caused by Vascular Dementia. But as with other stroke symptoms, cognitive changes may sometimes improve during recovery and rehabilitation from the acute phase of a stroke as the brain generates new blood vessels and brain cells outside the damaged region take on new roles.

One of the most effective treatments is controlling the risk factors for the disease. By preventing future damage to blood vessels of the brain, additional cognitive decline from Vascular Dementia is possible. Many of these recommendations are typical of what advised for reducing risk for many vascular conditions:

• The patients should not smoke.
• Blood pressure, cholesterol and blood sugar levels should be maintained within recommended limits.
• The patient should eat a healthy, balanced diet, exercise and maintain proper weight.
• Alcohol consumption should also be limited.

Similar to Alzheimer’s and other forms of dementia, Vascular Dementia can shorten a patient’s lifespan. Some data suggest that those who develop dementia following a stroke survive three years on average. Care partner support and end of life planning should always be considered as part of an effective care strategy to ensure that patients and families are ready to face the road ahead. Georgia Memory Net is ready to help with evaluating and treating Vascular Dementia and many other causes of cognitive decline.